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Background: Interest in the role of lateral extra-articular tenodesis (LET) in preventing rotatory instability and the pivot-shift phenomenon after anterior cruciate ligament reconstruction (ACLR) has been recently renewed. Nevertheless, there is still concern about overconstraint of the lateral compartment of the knee and the risk of subsequent osteoarthritis (OA). Purpose: The purpose of this retrospective study was to compare long-term subjective and objective outcomes and the rate of OA development between patients undergoing isolated ACLR (iACLR) with a hamstring tendon autograft and those with a combined Arnold-Coker modification of the McIntosh extra-articular procedure. Risk factors for long-term OA were evaluated. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 165 consecutive patients treated at a single center by ACLR. A total of 86 patients underwent iACLR (iACLR group) and 79 received combined intra- and extra-articular reconstruction (ACLR+LET). The International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores were administered. Knee stability was tested through the Lachman test, the pivot-shift test, and the KT-1000 knee arthrometer test. A positive pivot-shift test (++/+++), laxity on the KT-1000, and referred giving-way episodes or revision ACLR were considered failures. Radiographic results were assessed according to the Fairbank, IKDC, and Kellgren-Lawrence scales. Radiographic evaluation included both the overall tibiofemoral joint and the medial and lateral compartment separately. A univariate and a multivariate logistic regression with penalized maximum likelihood was used to identify risks factors associated with long-term OA. Results: The mean follow-up was 15.7 years. There were no statistically significant differences in subjective scores between the 2 groups. A side-to-side difference >5 mm on the KT-1000 arthrometer evaluation was found in 8 patients in the iACLR group and in 1 patient in the ACLR+LET group ( P = .01). Nine cases of failure were found in the iACLR group and only 1 case was found in the ACLR+LET group ( P = .0093). Patients in the iACLR group had a significantly higher OA grades than those in the ACLR+LET group for the overall tibiofemoral joint and the lateral compartment of the knee. No differences were found in the medial compartment. A higher level of lateral compartment OA was found in patients who received partial lateral meniscectomy in the iACLR group compared with those in the ACLR+LET group. Univariate and multivariate analysis results demonstrated that meniscectomy was the most significant factor for long-term OA development. Conclusion: A significantly higher risk of long-term OA was found with iACLR than with ACLR combined with the Arnold-Coker modification of the McIntosh extra-articular procedure. Knees with combined ACLR also had a significantly lower OA grade after partial lateral meniscectomy. Additionally, those undergoing combined ACLR had better knee stability and lower graft rupture rates at the long-term follow-up. Partial meniscectomy was the main risk factor negatively associated with OA changes.

Background:Preoperative grade 3 pivot shift has been reported to be associated with higher rates of anterior cruciate ligament (ACL) failure, persistent instability, and inferior patient-reported outcomes. The etiology of a high-grade pivot shift is multifactorial, and numerous factors have been suggested to be responsible. More attention has recently been focused on injury to the anterolateral structures (ALS) as a risk factor for a grade 3 pivot shift.Purpose:To determine risk factors for grade 3 pivot shift, including soft tissue and osseous parameters.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A prospective evaluation was undertaken of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury). An open exploration of the lateral side of the injured knee was performed at the time of the index procedure. Details regarding patient and injury characteristics were recorded, as were details of soft tissue injuries, including meniscal tears, ALS lesions, medial collateral ligament tears, and chondral injuries. Osseous parameters (tibial slope and condylar ratios) were determined per established magnetic resonance imaging protocols. A multivariate logistic regression with penalized maximum likelihood was used to identify risk factors associated with International Knee Documentation Committee (IKDC) grade 3 pivot shift.Results:The mean ± SD age of the population was 28.3 ± 9.8 years; 67.5% of patients were male. Among patients, 35 (17.5%) had a high-grade pivot shift (IKDC grade 3), and 165 (82.5%) had a low-grade pivot shift (IKDC grades 1 and 2). Univariate and multivariate logistic regression analysis demonstrated that injury to the ALS was the only significant risk factor for grade 3 pivot shift (odds ratio, 13.49; 95% CI, 1.80-1725.53).Conclusion:This comprehensive evaluation of soft tissue and osseous factors has identified that injury to the ALS is the most important risk factor for grade 3 pivot shift in acute ACL-injured knees.

Despite growing attention to the ability of patients to provide informed consent to treatment in different medical settings, few studies have dealt with the issue of informed consent to major orthopaedic surgery in those over the age of 60. This population is at risk of impaired decision-making capacity (DMC) because older age is often associated with a decline in cognitive function, and they often present with anxiety and depressive symptoms, which could also affect their capacity to consent to treatment. Consent to major orthopaedic surgery requires the patient to understand, retain and reason about complex procedures. This study was undertaken to extend the literature on decisional capacity to consent to surgery and anaesthesia of patients over the age of 60 undergoing major orthopaedic surgery. Recruited patients ( N=83) were evaluated using the Aid to Capacity Evaluation, the Beck Depression Inventory, the State–Trait Anxiety Inventory Y, the Mini-Mental State Examination and a visual analogue scale for measuring pain symptomatology. Impairment of medical DMC was common in the overall sample, with about 50% of the recruited patients showing a doubtful ability, or overt inability, to provide informed consent. Poor cognitive functioning was associated with reduced medical DMC, although no association was found between decisional capacity and depressive, anxiety and pain symptoms. These findings underline the need of an in-depth assessment of capacity in older patients undergoing major orthopaedic surgery.

Background: Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction is associated with improved clinical outcomes as compared with isolated intra-articular reconstruction, but the indications are not precisely defined. It may be the case that patients with proven anterolateral injury on preoperative imaging are most likely to benefit, but the accuracy of magnetic resonance imaging (MRI) is not known. Purpose/Hypothesis: To evaluate the correlation between MRI and surgical exploration in acute ACL-injured knees. The hypothesis was that a positive correlation would be identified between imaging and surgical findings for ALL/capsule and iliotibial band (ITB) injuries and that MRI would be highly sensitive, specific, and accurate. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Between January and May 2016, patients presenting with acute ACL injuries were considered for study eligibility. Included patients underwent 1.5-T MRI, which was evaluated by 3 investigators who attributed a Ferretti grade of injury to the anterolateral structures. At the time of ACL reconstruction, a lateral exploration was undertaken, and macroscopic injuries were identified. An evaluation of correlation between MRI and surgical exploration findings was performed. Results: Twenty-six patients participated in the study, and 96% had an ALL/capsule injury. The sensitivity, specificity, and accuracy of MRI and the correlation ( K) with surgical exploration findings were as follows, respectively: any ALL/capsule abnormality—88%, 100%, 88.5%, and 0.47; differentiating partial or complete ALL/capsule tears—78.6%, 41.7%, 61.5%, and 0.23; ITB injuries—62.5%, 40%, 50%, and 0.27. The percentage agreement between MRI and surgical findings was 88% for ALL/capsule injury, 65% for ITB injury, and 53% for Ferretti grading. Conclusion: Surgical exploration demonstrates that injuries occur to the anterolateral structures in almost all acute ACL-injured knees. MRI is highly sensitive, specific, and accurate for detection of abnormalities of the ALL/capsule and shows a high percentage of agreement with surgical findings. MRI has low sensitivity, specificity, and accuracy for the diagnosis of ITB injury. The Ferretti grade could not be reliably established from MRI, and there was only fair agreement between MRI and surgical findings with respect to ITB abnormalities and determination of whether ALL/capsular tears were partial or complete.

Background: The injury rate in professional soccer players may be influenced by match frequency. Purpose: To assess how changes in match frequency that occurred because of coronavirus disease 2019 (COVID-19) influenced training and match injuries in the Italian Serie A league. Study Design: Descriptive epidemiology study. Methods: Three phases in the Serie A league, each 41 days long, were evaluated: phase A was the beginning of the 2019-2020 season; phase B was a period after the COVID-19 lockdown was lifted, when the remaining matches of the season were played with greater frequency; and phase C was the beginning of the 2020-2021 season. All male professional soccer players who were injured during the 3 phases were included. Player age, height, position, injury history, and return to play (RTP) were retrieved from a publicly available website. Training- and match-related injuries during each of the 3 phases were collected and compared. Moreover, match injuries that occurred after the lockdown phase (phase B), in which there were 12 days designated for playing matches (“match-days”), were compared with injuries in the first 12 match-days of phases A and C. Results: When comparing 41-day periods, we observed the injury burden (per 1000 exposure-hours) was significantly lower in phase B (278.99 days absent) than in phase A (425.4 days absent; P < .05) and phase C (484.76 days absent; P < .05). A longer mean RTP period was recorded in phase A than in phase B (44.6 vs 23.1 days; P < .05). Regarding 12–match day periods (81 days in phase A, 41 days in phase B, and 89 days in phase C), there was a significantly higher match injury rate (0.56 vs 0.39 injuries/1000 exposure-hours; P < .05) and incidence (11.8% vs 9.3%; P < .05) in phase B than in phase A and a longer mean RTP period in phase A than in phase B (41.8 vs 23.1 days; P < .05). Finally, the rate and incidence of training-related injuries were significantly higher in phase B (4.6 injuries/1000 exposure-hours and 6.5, respectively) than in phase A (1.41 injuries/1000 exposure-hours and 2.04, respectively) ( P < .05). Conclusion: Both training- and match-related injuries were greater during the abbreviated period after the COVID-19 lockdown. These may be linked to the greater match frequency of that period.

Objectives: The objective was to compare the clinical results of ACL and ALL repair with those of standard ACL reconstruction + LET. The hypothesis was that combined repair is non-inferior to standard reconstruction + LET in adults with acute anterolateral knee instability. Methods: Patients with severe acute anterolateral instability (ACL + ALL injuries) who underwent early ACL surgery (injury-to-surgery interval < 14 days), a total of 58 patients, were prospectively enrolled in the study. ACL injuries were classified according to the Sherman classification. Patients with a proximal injury (types 1 and 2) were assigned to receive ACL repair (ACLrep) (n = 37), patients with types 3 and 4 and moderate tissue quality (n = 21) were assigned to receive ACL reconstruction (ACLrec) + lateral extra-articular tenodesis (LET). Repair consisted of transosseous suture of the stump to the anatomic origin of the ACL and direct repair of the ALL. Reconstruction consisted of standard ACL reconstruction by semitendinosus-gracilis (STG) autograft + LET. PROMs included IKDC, Lysholm, KOOS, and assessment of anteroposterior (AP) knee laxity in 2 years. Results: A sample size calculation showed that 21 patients in each group were needed for a 95% power (with a 95% CI) to show non-inferiority of the repair group considering an arthrometric side-to-side difference of at least +1.5. Patients in the ACLrep group showed better results on all scales: mean IKDC was 95.51 ± 52.4 versus 86.92 ± 13.92 (p = 0.02); mean KOOS was 97.49 ± 2.71 versus 93.50 ± 7.05 (p = 0.009); and mean Lysholm was 96.98 ± 5.14 versus 91.69 ± 10.08 (p = 0.02). There was no difference in the KT1000 measurement (ACLrep: 1.70 ± 1.02; ACLrec: 2.21 ± 0.80; p = 0.11). The one-sided 95% CI was 1.7 (to 2.02) (< at the 3.01 limit for non-inferiority) for ACLrep and 2.21 (to 2.46) for ACLrec, p = 0.147. Therefore, non-inferiority was proven Conclusion: In acute knee instability resulting from a combined ACL and ALL injury, direct repair is non-inferior in terms of PROM and knee laxity compared to standard ACL + LET reconstruction in 2 years.

Background: The anterolateral ligament (ALL) has been identified as a structure on the lateral side of the knee, but debate exists regarding whether it is a capsular thickening or a ligament. Hypothesis: A detailed ultrastructural characterization of the ALL and its ultrastructure collagen arrangement will reveal it more closely resembles ligamentous tissue than joint capsule. Study Design: Descriptive laboratory study. Methods: Eight paired knee samples from 4 fresh-frozen male cadavers were used for this study. Samples were harvested from the ALL, the joint capsule, and the medial collateral ligament (MCL). All samples were evaluated with light microscopy (LM), transmission electron microscopy (TEM), and variable pressure scanning electron microscopy (VP-SEM). With LM, the 3 tissues were analyzed and their morphology described. With TEM, the ultrastructure and collagen characteristics were quantified and compared among specimens. Then, the 3-dimensional characteristics were compared with VP-SEM. Results: Ultrastructure analysis demonstrated similar morphology between the ALL and MCL, with significant differences in these 2 structures as compared with the joint capsule. On LM, the ALL and MCL were characterized by the presence of a dense collagen fiber oriented in the longitudinal and transversal directions of the fiber bundles, while the joint capsule was found to have a more disorganized architecture. On TEM, the collagen fibers of the ALL and MCL demonstrated similar ultrastructural morphology, with both having collagen fibers in parallel, longitudinal alignment. A quantitative analysis was also performed, with the mean (± SD) diameter of fibrils in the ALL and MCL being 80 ± 2.66 nm and 150 ± 3.35 nm, respectively (all P < .001). The VP-SEM highlighted that ALL and MCL morphology demonstrated arrangements of fiber bundles that are densely packed and organized, in contrast to the disorganized fibers of the joint capsule. Conclusion: The ALL and MCL have comparable ultrastructures that are distinctly different from the joint capsule, as visualized on LM, TEM, and VP-SEM. Clinical Relevance: The ALL should be considered a distinctive structure of the knee, although strictly connected to the surrounding capsule.

Background: Broad variation in the reported rate of magnetic resonance imaging (MRI)–detected abnormalities of the anterolateral structures of the anterior cruciate ligament (ACL)–injured knee suggests a lack of reliability that has limited the use of MRI in clinical decision making. Purpose/Hypothesis: The aim of this study was to use MRI to determine the prevalence and spectrum of abnormalities of the anterolateral structures in acute ACL-injured knees, using the contralateral uninjured knee as a reference. We hypothesized that MRI evaluation of the acutely injured knee (using the uninjured knee as a reference) would allow reliable identification of abnormalities of the anterolateral structures. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Patients with acute ACL injury underwent MRI scan of both knees. Images were evaluated by 3 observers. Inter- and intraobserver reliabilities were determined for MRI parameters of anterolateral ligament (ALL) injury by use of the kappa (κ) test. Univariate and multivariate analyses were conducted to test associations between ALL abnormality and associated injuries. Results: A total of 34 patients were evaluated. Of these, 30 patients (88.2%) had at least 1 ALL abnormality in the ACL-injured knee (increased signal: n = 27[79.4%]; increased thickness: n = 15[44.1%]; tapering: n = 7[20.6%]; irregularities in the path of the ALL fibers: n = 21[61.7%]). Asymmetries of the genicular vessels were observed in 21 patients (61.7%). ALL abnormality was significantly associated with lateral joint capsular tears ( P < .001). No correlation was found between ALL lesions and iliotibial band lesions ( P = .49). Inter- and intraobserver reliabilities were very good concerning ALL signal changes and femoral and tibial bone bruises (κ coefficient, 0.81-1). Conclusion: MRI evaluation of the ALL was associated with good and very good inter- and intraobserver reliabilities, and it demonstrated abnormalities of the ALL in the majority of acutely ACL-injured knees. The index of suspicion for ALL injury should be elevated by the presence of lesions of the lateral capsule. This suggests that the ALL is part of a wider area of the lateral capsule that is often injured simultaneously in an acute ACL tear.

Background: Tendinopathies represent a serious challenge for orthopaedic surgeons involved in treatment of athletes. Purpose: To compare the effectiveness and safety of platelet-rich plasma (PRP) injections and focused extracorporeal shock wave therapy (ESWT) in athletes with jumper’s knee. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Forty-six consecutive athletes with jumper’s knee were selected for this study and randomized into 2 treatment groups: 2 autologous PRP injections over 2 weeks under ultrasound guidance (PRP group; n = 23), and 3 sessions of focused extracorporeal shock wave therapy (2.400 impulses at 0.17-0.25 mJ/mm2 per session) (ESWT group; n = 23). The outcome measures were Victorian Institute of Sports Assessment–Patella (VISA-P) questionnaire, pain visual analog scale (VAS), and modified Blazina scale. A reviewer who was blinded as to the group allocation of participants performed outcome assessments before treatment and at 2, 6, and 12 months after treatment. Nonparametric tests were used for within-group (Friedman/Wilcoxon test) and between-group (Kruskal-Wallis/Fisher test) testing, and the significance level was set at .05. Results: The 2 groups were homogeneous in terms of age, sex, level of sports participation, and pretreatment clinical status. Patients in both groups showed statistically significant improvement of symptoms at all follow-up assessments. The VISA-P, VAS, and modified Blazina scale scores showed no significant differences between groups at 2-month follow-up ( P = .635, .360, and .339, respectively). The PRP group showed significantly better improvement than the ESWT group in VISA-P, VAS scores at 6- and 12-month follow-up, and modified Blazina scale score at 12-month follow-up ( P < .05 for all). Conclusion: Therapeutic injections of PRP lead to better midterm clinical results compared with focused ESWT in the treatment of jumper’s knee in athletes.

Background: Increased femoral tunnel widening and weakness of the hamstring muscles postoperatively have been described as potential adverse events after anterior cruciate ligament (ACL) reconstruction (ACLR) with a hamstring graft. Meniscectomy and cartilage lesions are important factors for the development of degenerative osteoarthritis. Purpose: To compare 15-year follow-up data with 5-year follow-up data from the same cohort of patients after ACLR with a hamstring autograft using an outside-in technique. Study Design: Case series; Level of evidence, 4. Methods: A total of 72 patients who underwent anatomic ACLR with a quadruple hamstring graft and an outside-in technique were selected for this prospective study. Patients were reviewed at a minimum follow-up of 15 years. Results were compared with the same series of patients previously reviewed at 5 years after surgery. Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores as well as KT-1000 arthrometer measurements were obtained at final follow-up. Comparative weightbearing radiographs were obtained and analyzed according to the Fairbank, Kellgren-Lawrence, and IKDC classifications and used for the tunnel evaluation. Results: No significant difference was detected on the subjective evaluation. Objectively, patients categorized as A or B according to the IKDC score were not significantly different at 5 and 15 years ( P < .01). A KT-1000 arthrometer side-to-side manual maximum difference >5 mm, a pivot shift >2+, any giving-way episode, and ACL revision surgery were considered as failures, and these were noted in 6 patients at 5 years and 6 patients at 15 years. The radiological evaluation at 15 years showed a higher rate of osteoarthritis in 2 of 3 radiological scales used in the study compared with results at 5-year follow-up ( P < .01). At 15-year follow-up, there was a statistically significant reduction in the mean tibial tunnel diameter ( P < .01). Conclusion: Endoscopic single-bundle ACLR using hamstring grafts and an outside-in technique demonstrated good results at 15-year follow-up in terms of subjective, objective, and radiographic evaluations. As compared with 5-year follow-up, clinical results remained stable both subjectively and objectively. However, a progression of osteoarthritis changes was observed, especially in patients in whom meniscectomy had been performed.

BackgroundThe biomechanical function of single-bundle anterior cruciate ligament reconstruction, in cadaveric studies, is successful in limiting anterior tibial translation in response to an anterior tibial load but seems to be insufficient to control a combined rotator load of internal and valgus torque. Anatomical double-bundle anterior cruciate ligament reconstruction might produce a better biomechanical outcome.HypothesisThe addition of the posterolateral bundle to the anteromedial bundle, in an in vivo double-bundle computer-assisted anterior cruciate ligament reconstruction, is able to reduce internal rotation of the tibia at 30° of knee flexion, compared with a standard single-bundle reconstruction.Study DesignControlled laboratory study.MethodsTwenty consecutive anterior cruciate ligament reconstructions were performed in male patients in April and May 2006 with double-bundle gracilis and semitendinosus tendon grafts using the 2.0 OrthoPilot navigation system. Group A (10 patients) underwent standard single-bundle anterior cruciate ligament reconstruction with doubled gracilis and semitendinosus tendon graft; group B (10 patients) underwent double-bundle reconstruction with doubled gracilis and semitendinosus tendon graft. Anteroposterior displacement and internal and external rotation at 30° of knee flexion were evaluated before and after reconstruction, using manual maximum force.ResultsBoth techniques significantly reduced anteroposterior displacement and internal and external rotation of the tibia with respect to preoperative anterior cruciate ligament–deficient condition ( P < .05). Comparing groups, no differences in anteroposterior tibial displacement and internal and external rotation of the tibia were found (anteroposterior, 3.7 mm and 5.2 mm; internal rotation, 16.3° and 16.6°; external rotation, 15.7° and 15.1°, respectively) in group A and B ( P = .06, .90, and .72, respectively).ConclusionThe hypothesis that addition of the posterolateral bundle to the anteromedial bundle is able to reduce internal rotation of the tibia at 30° of knee flexion is not confirmed.Clinical RelevanceThe effective role of the anatomical double-bundle procedure in better restoring knee kinematics should be questioned in an in vivo model.

Minimally invasive surgery has become a trend over the last few years in all aspects of orthopaedic surgery, including total hip arthroplasty So-called “mini-incision” techniques involve limiting the length of the skin incision to ≤ 10 cm with use of either an anterior, lateral or posterior approach. Between March 2004 and December 2005 one hundred consecutive unilateral total hip replacements were performed by the same senior surgeon in our institute. All patients were randomly assigned to study group (group A) or control group (group B). In group A (50 patients) the skin incision was ≤ 8 cm; in group B (50 patients) the skin incision was standard (about 12–14 cm). Patient demographic data, including sex, age, height, weight, BMI, diagnosis and preoperative Harris hip score were recorded. Other criteria evaluated included the perioperative and postoperative complications, the surgical time, the blood loss, the length of the incision, the acetabular and stem positions, the length of hospital stay, Harris Hip Score (HHS) and the WOMAC osteoarthritis index at six months. No significant differences were found between the groups with respect to the average surgical time, the acetabular and stem position, the length of hospital stay and the Harris Hip Score (HHS) and the WOMAC osteoarthritis index at six months. A significant lower blood loss was found in the mini-incision group. A higher percentage of peri-operative complications was recorded in Group A (two stupor of sciatic nerve and one fracture of the greater trochanter). On the basis of our experience we could speculate that minimally invasive surgery should be directed to the new surgical approach with muscle sparing, instead of a shorter skin incision using standard approaches.

Background The weakest points in hamstrings anterior cruciate ligament reconstruction are its points of fixation, especially on the tibial side. Methods for graft fixation to bone should be strong enough to avoid failure, stiff enough to restore load-displacement response, and secure enough to resist slippage under cyclic loading. Hypothesis Biomechanical properties of the interference screw can be improved by reinforcing the walls of the tunnel with a metal spiral (Evolgate fixation). Study Design Controlled laboratory study. Methods Three paired tests were performed using common digital extensor bovine tendons fixed to porcine tibias with interference screw, Intrafix, and Evolgate; critical graft fixation conditions were simulated by applying subsequent cycles to the graft before loading the graft until failure. Results The strength, stiffness, and resistance to slippage of the Evolgate were significantly higher than those of the interference screw; the ultimate failure load of the Evolgate was significantly higher than that of the Intrafix (1058 ± 130 N and 832 ± 156 N, respectively; P =. 02). No statistically significant differences were found between Evolgate and Intrafix regarding the stiffness and slippage under cyclic load. Conclusion Evolgate fixation seems to be stronger, stiffer, and more resistant to slippage than is interference screw fixation of similar length, and it is stronger but not stiffer than Intrafix. Clinical Relevance The Evolgate provides structural properties that seem to be appropriate for an intensive rehabilitation after anterior cruciate ligament reconstruction using a doubled semitendinosus and gracilis graft.

We describe the histologic course of regenerated tissue simulating the semitendinosus tendon in three patients after anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons. Specimens were retrieved during revision surgery for removal of tibial hardware at 6, 24, and 27 months, respectively. Resisted flexion during physical examination in all patients revealed a “string” on the posteromedial aspect of the knee that was quite evident, suggesting the presence of a regenerated semitendinosus tendon. At surgery, a well-defined fibrous band was identified about 3 cm proximal and medial to the pes anserinus, reproducing the pathway of the native semitendinosus tendon. In the specimen retrieved 6 months postoperatively, a prominent fibroblastic proliferation was observed together with a few vessels surrounded by fibrous tissue; only a few bundles of well-oriented collagen fibers were present, together with scattered rows of spindle-shaped cells. In both of the specimens retrieved 2 years postoperatively, all of the central, thicker portion of each specimen was occupied by well-oriented tendon-like fibers together with uniformly distributed spindle-shaped cells that had the appearance of mature tenocytes arranged in orderly rows. These findings help us to understand the progression of the healing process at the harvest site and the nature of the regenerated semitendinosus tendon, which has previously been investigated only by studies of clinical and functional outcomes and by imaging studies.

Background: The Segond fracture is an avulsion-type fracture located on the anterolateral aspect of the tibia associated with a ligament recently termed the anterolateral ligament. This injury has been described as pathognomonic for an anterior cruciate ligament (ACL) tear and is associated with a higher grade pivot shift. Purpose: To present and report 2-year clinical outcomes of a surgical technique for acute ACL reconstruction with fixation of a concomitant Segond fracture. Study Design: Case series; Level of evidence, 4. Methods: A retrospective chart review was performed of patients who underwent acute reconstruction for a complete ACL tear with concomitant Segond fracture fixation between January 2010 and December 2014; surgery was performed by a single surgeon. Patients underwent direct Segond fracture repair by either suture alone, suture anchor, or cannulated screw fixation based on the size of the lesion, followed by a 2-incision hamstring autograft intra-articular reconstruction. Pre- and postoperative KT-1000 arthrometer assessment, Lachman test, and pivot-shift test were performed, and patients were administered validated subjective outcome surveys. Results: Twelve patients met inclusion criteria for this review. The measured pre- and postoperative objective and subjective scores were significantly improved in all patients. Side-to-side anterior laxity was significantly improved in all patients based on Lachman and KT-1000 arthrometer testing. A significant pivot shift demonstrated preoperatively (3+, n = 11 [92%]; 2+, n = 1 [8%]) was corrected after fixation, except in 1 patient (8%), who maintained a 1+ pivot shift. Lysholm, Tegner, and International Knee Documentation Committee subjective and objective scores were significantly improved. At a minimum 2-year follow-up, no patients reported rerupture, and only 1 patient (8%) underwent a subsequent procedure (a meniscectomy). No major or minor complications were reported, and all patients returned to their previous activity levels at a mean of 6 months postoperatively. Conclusion: Direct repair of the Segond fracture and plication of the anterolateral capsule in patients with an ACL rupture and a high-grade pivot shift demonstrate good clinical outcomes, restoration of rotational stability, and maintenance of knee range of motion at 2 years postoperatively, with no major complications.

From 1985 to 1996, we observed 38 cases of isolated atrophy of the infraspinatus muscle in athletes; all were involved in volleyball at a competitive level. There were 20 men and 18 women with a mean age of 26 years (range, 15 to 27). At the time of the first examination, 35 of these athletes had no pain and were treated with exercises to strengthen the external rotators. The remaining three patients underwent surgery because of pain at the posterior aspect of the shoulder. Sixteen of the 35 players treated nonoperatively were reviewed at a mean follow-up of 5.5 years (range, 3 to 10). Thirteen were still involved in volleyball and three had retired symptom-free at the end of their careers. On physical examination, atrophy of the infraspinatus muscle was unchanged in all cases. The patients treated surgically were reviewed at a mean follow-up of 2 years. All of them were able to play volleyball at their preinjury levels, but one had pain at the anterior aspect of the shoulder after strenuous activity. Physical examination showed a notable reduction of the atrophy in one patient. Entrapment of the suprascapular nerve at the spinoglenoid notch is a usually painless syndrome that is frequently observed in volleyball players. Surgical treatment is indicated in the rare cases of painful neuropathies after careful patient selection.

Forty of 42 consecutive open capsulorrhaphies with suture anchors for treatment of traumatic recurrent anterior dislocation of the shoulder were reviewed after a minimum follow-up of 2 years. Two patients were lost to follow-up. Follow-up was conducted according to the rating systems of Rowe and the Society of American Shoulder and Elbow Surgeons. The surgical outcome was satisfactory in 38 patients (95%). Eighteen of the 22 patients who were involved in competitive overhead or collision sports before surgery returned to their preoperative sports levels. One patient, whose operation was unsuccessful, experienced recurrent dislocation. In one patient, a deep infection that occurred as a complication of the surgical technique healed after suture anchor removal. Although a longer follow-up is necessary, this technique appears to have encouraging results as it avoids the risks related to the use of screws and staples.

In this study, we surveyed a consecutive series of 500 patients who had undergone an open procedure for chronic anteromedial and/or anterolateral instabilities. Those patients who had an open arthrotomy were separated for analysis. All of the patients were examined before and during surgery. A knee sheet, based on the kind used at the Hughston Orthopaedic Clinic in Columbus, Georgia, was used to record all clinical findings. Chondromalacia of the articular surface of the femur was detected at surgery in 161 patients (32%). A statistical analysis showed that the variables di rectly influencing degenerative changes of the cartilage are: a previous surgery that did not sufficiently restore joint kinematics (chi square = 20.238, P < 0.001) and a time lapse of more than 30 months between first trauma and surgery (chi square = 21.736; P = 0.001). A higher score on dynamic (jerk or pivot shift) and static (internal and external anterior drawer) tests, in dicating instability, or a meniscal tear alone do not statistically correlate with chondromalacia, but together they influence degenerative changes of the cartilage.

Jumper's knee (patellar or quadriceps tendon tendon itis) is found in a high number of athletes, especially in volleyball and basketball players. Conservative treatment (rest, stretching, physical therapy and an tiinflammatory drugs) is usually successful. The ath letes often recover completely and resume their sports activity. The purpose of this study is to present the histologic findings and our surgical repair of 18 knees of patients who underwent surgery after failure of conservative treatment. Histologic findings confirm that the so-called "jumper's knee" is a pathology localized at the bone- tendon junction. In all cases the following abnormali ties were found:pseudocystic cavities at the borderline between mineralized fibrocartilage and bone, disap pearance of the "blue line," increased thickness of the insertional fibrocartilage with myxomatous and hyaline metaplasia, mineralization, and ossification of the fibrocartilage far from the "blue line." Abnormali ties of the patellar tendon were observed only in one patient who received local injection of corticosteroids. Eleven of the 18 surgically treated knees obtained a satisfactory result with complete resumption of sports activity.